Nokea
The nurse is performing a developmental assessment on a 12-month-old client. Which of the following findings are expected at this age? Select all that apply.
- A. Birth weight has tripled
- B. Cruises along furniture
- C. Kicks a ball
- D. Searches for hidden objects
- E. Speaks in two word phrases
Correct Answer: A,B,D
Rationale: By 12 months, infants typically triple birth weight, cruise along furniture, and search for hidden objects (object permanence). Kicking a ball and two-word phrases are expected at 18-24 months.
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The parent of a child treated for injuries consistent with suspected child abuse has been told that a report will be made to Child Protective Services (CPS). The parent says angrily to the nurse, 'I don’t know why this is being reported. I told the health care provider (HCP) that it was an accident.' What is the best response by the nurse?
- A. A case worker from CPS will be visiting you in a few days. The case worker can explain it to you then
- B. Did you ask the HCP why it is being reported?
- C. Reporting your child’s injuries is required by law. It is for your child’s safety and protection
- D. Your explanation of your child’s injuries does not seem plausible
Correct Answer: C
Rationale: Explaining that reporting is legally mandated for child safety is factual and nonjudgmental. Deferring to CPS, questioning the parent, or doubting their explanation may escalate tension or avoid responsibility.
The nurse is acting as a preceptor for a student nurse in the labor and delivery unit. Which action by the student would require correction by the nurse?
- A. Removing gloves prior to removing isolation gown
- B. Using a nail brush to scrub underneath artificial nails
- C. Using alcohol-based hand sanitizer instead of washing hands when entering and exiting client room
- D. Washing hands and not wearing gloves when preparing medications in the med room
Correct Answer: B
Rationale: Artificial nails harbor bacteria, and scrubbing underneath is inadequate; they should be avoided in labor and delivery. Other actions align with infection control protocols.
A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse reinforces teaching to the client that the pain will improve with which of the following?
- A. Coughing and deep breathing
- B. Left lateral position
- C. Pursed lip breathing
- D. Sitting up and leaning forward
Correct Answer: D
Rationale: Sitting up and leaning forward reduces pressure on the pericardium, relieving pericarditis pain. Coughing, lateral positioning, and pursed-lip breathing do not alleviate pericardial pain.
The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience
- A. high fever
- B. nausea
- C. face and neck edema
- D. night sweats
Correct Answer: B
Rationale: nausea. Because the client with Hodgkin's disease is usually healthy when therapy begins, the nausea is especially troubling.
A client who had a bowel resection 5 days ago says, 'I felt like I split open when I coughed.' The nurse finds the incision edges separated and bowel protruding through the wound. Which of the following actions are appropriate? Select all that apply.
- A. Administer 1 oral tablet of oxycodone prescribed PRN for pain
- B. Collect a full set of vital signs
- C. Cover the viscera with sterile dressings saturated in normal saline solution
- D. Notify the health care provider immediately
- E. Place the client in the low Fowler position with knees slightly flexed
Correct Answer: B,C,D,E
Rationale: Vital signs, sterile saline dressings, provider notification, and low Fowler with flexed knees manage dehiscence and evisceration. Oxycodone is inappropriate during this emergency.